This blog follows the history of psychiatry

Historian of psychiatry Edward Shorter, author of numerous books including A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (1997); Before Prozac. The Troubled History of Mood Disorders in Psychiatry (2009) and How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown (2013), has published a new book:

What Psychiatry Left Out of the DSM-5

Historically-Based Mental Disorders and the DSM: What Psychiatry Left Out covers the diagnoses that the Diagnostic and Statistical Manual of Mental Disorders (DSM) failed to include, along with diagnoses that should not have been included, but were. Psychiatry as a field is over two centuries old and over that time has gathered great wisdom about mental illnesses. Today, much of that knowledge has been ignored and we have diagnoses such as “schizophrenia” and “bipolar disorder” that do not correspond to the diseases found in nature; we have also left out disease labels that on a historical basis may be real. Edward Shorter proposes a history-driven alternative to the DSM.

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Psychiatrist Allen Frances, Professor Emeritus at Duke University and Chair of the DSM-IV Task Force, has published a new article in The Huffington Post today centered on the history of psychiatry. The piece also features the work of University of Toronto historian of medicine Edward Shorter. It is entitled “Is This the Worst Time Ever to Have a Severe Mental Illness?”

Is This the Worst Time Ever to Have a Severe Mental Illness?

My personal response to this depressing question would have to be an ashamed ‘Yes’ for the United States; a relieved ‘No’ for most of the rest of the developed world.

Admittedly, though, I am not the best person to provide a long view answer. We will soon be turning to Professor Edward Shorter, an eminent historian of psychiatry, to compare our current mistreatment of the severely ill with the practices of past epochs.

But I can speak from painful experience about the slippery downward slope of the past 50 years. When I first began work as a medical student on a psychiatric ward, we were very very optimistic that three new advances would dramatically improve the lives of our patients: 1) the availability of effective medication; 2) the availability of powerful research tools; and 3) the hope that state hospitals would disappear as patients were deinstitutionalized into the community.

Forty years ago, my optimism collided with reality when I was given charge of a short term inpatient ward. The medicines sometimes did work wonders, but often brought only partial relief and caused unpleasant side effects. The research findings were fascinating, but didn’t have any impact on patient care. And worst of all, it was clear from the outset that deinstitutionalization was being carried out so badly it was bound to fail.

Patients were irresponsibly discharged at breakneck speed with little or no provision for their housing or treatment in the community. They were left to sink or swim on their own and not surprisingly many sank.

The dream of deinstitutionalization turned into nightmare because most state governments didn’t, as promised, use the money saved by closing beds to provide adequate community treatment and housing. Deinstitutionalization was great for the state budget, but often terrible for the patients.

Many wound up on our unit. I am still haunted by a man I had to cut down after he had hanged himself in our shower room — he couldn’t tolerate his fallen status from chief car washer in the state hospital to deinstitutionalized street person.

In Europe, deinstitutionalization was usually done much better — with a sense of social justice, adequate funding, decent housing, and greater family involvement. Originally, there were also some excellent programs in the United States, but most of these have been eroded with time under pressure from shrinking budgets and the cherry picking of easier patients that accompanied privatization.

The severely ill are now often jailed or homeless — worse off than they were when I started psychiatry. For more on this heartbreaking development, see this blog post and a dozen others I have written.

Now we’re going to shift gears from my personal experiences to Edward Shorter’s historical perspective. He is professor of the history of medicine and professor of psychiatry at the University of Toronto and has written widely on the past and current problems of psychiatry. Professor Shorter writes:

“What was it like being a psychiatric patient in the remote past? Before 1800, before Philippe Pinel, things were quite grim. People often believed that mental symptoms were caused by demonic possession and took the ill to priests for painful, sometimes fatal, exorcism. Psychiatric patients were sometimes, if female, regarded as witches and burned at the stake.

Physicians, while not believing in demons, thought the abdomen — especially the spleen and colon — was the site of mental illness and treated patients with laxatives. Bleeding and many other futile and dangerous treatments were also routine.

There were no dedicated mental hospitals. Patients who needed to be swept off big-city streets were thrown into ‘hospices,’ together with the criminal, the medically sick, the elderly, and the poor. In smaller communities, mentally affected relatives might simply be locked in the attic or chained in the barn.

A fantasy has arisen among the followers of Parisian philosophy professor Michel Foucault that traditional societies viewed the mentally ill benignly — permitting them to drink red wine on the village commons all afternoon as the neighbors looked on smilingly. In the Foucauldian version of history, the downward slide of the mentally ill begins with ‘capitalism’ and the modern state, as the former benignly neglected denizens of the village commons were now ‘confined’ in barrack-like asylums.

Nothing could be further from the truth. Around 1800, proper mental hospitals were founded. These were intended to be, and originally were, humane institutions-the well-ordered routines of a hospital would restore a sense of order and normalcy; its high walls would grant a sense of safety; and medical reassurance constituted an early form of psychotherapy.

The wheels started to come off the wagon when these praiseworthy intentions were overwhelmed by the sheer press of numbers. Yet a core reality remained: For many, the asylum was a place of safety.

Since deinstitutionalization and the death of the asylum, the care of very ill psychiatric patients has gotten much worse. Psychiatry’s dirty secret is that if you had a severe mental illness requiring hospital care in 1900, you’d be better looked after than you are today. Despite a flurry of media hand-waving about new technologies in psychiatry, the average hospital patient probably does less well now, despite the new drugs, than the average hospital patient a century ago.

How can this be? Above all, the old asylums were committed to keeping the patients safe. A major source of mortality (aside from tuberculosis) was suicide, and the best way to preserve patients from suicide is to hold onto them until they are better. As David Healy’s research group has determined, in one British mental hospital around 1900, the average stay was 302 days, versus 41 days in the same hospital today. Suicide rates within ten years of discharge are much higher now despite the availability of drugs. In 1900, among patients with schizophrenia, 4 had killed themselves within ten years of discharge; today in a roughly similar population, it was 29. Note that most psychiatric inpatient units in the US now have a length of stay that has been shortened to an incredible 7 days — far too short to stabilize patients and keep them safe.

I am not trashing today’s psychopharmaceutical palette. Many patients are clearly better off with drugs than without them. Yet the crucial factor here is length of stay: the stays then were long (sometimes far too long); the stays now are ultra-brief and patients are discharged well before they are able to cope — especially since so few services are available in the community and adequate housing is in such short supply.

The old institutions were not wonderful — they were overcrowded, noisy, and often had a distinctive odor. Patients were neglected and mistreated. Yet those problems have been replaced with a different set: patients today are far too often relegated to jails and prisons, where their vulnerability leads to frequent solitary confinement and physical and sexual abuse. Patients used to work at productive jobs within the institutions; no longer available now that we’ve abolished the shelter the hospitals provided.

When in the 1970s the hospital administrators and state legislators began the massive program of deinstitutionalization — returning the patients to the community — it was under the pretense that they were being discharged to ‘community care,’ to a network of halfway houses and day clinics where they would be looked after and kept safe.

Guess what? Never happened. The well-meant institutions of community care foundered and sank, sometimes because of lack of money, or an antipsychiatry inspired belief that there was no such thing as mental illness and that problems could be treated with kindness alone. I am not against kindness, but some patients are very ill and need genuine medical treatments. Many patients today, booted from the former security of the asylum, find themselves on the street with no care at all or in prison. This is a national scandal and the term “progress in psychiatry” turns out to be cruelly ironic.”

Thanks so much, Professor Shorter, for providing this brief but illuminating historical context. There are two contradictory views on the study of history: 1) If we don’t learn from history, we are doomed to repeat it, versus 2) The one thing we learn from history is that we don’t learn from history. I am inclined to believe the second, but am unwilling to give up on the possibilities suggested by the first.

An Alternative, History-Based, Nosology for Psychiatry

For their comments on earlier versions, the author would like to thank Tom Bolwig, Bernard Carroll, Max Fink, Gordon Parker, Robert Rubin, Michael Alan Taylor, and Lee Wachtel.

Current efforts to produce a classification of disease have not turned out well. The fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) was released to general dismay in May 2013. The current DSM, though vastly influenced by history, pays little attention to it, either in the form of attributing significance to patients’ own histories or in acknowledging the historical diagnostic traditions of psychiatry.

Yet it is possible to take history as our guide in drawing up classifications of diseases. Here is an analogy: In Traditional Chinese Medicine a sifting process lasting thousands of years has taken place to winnow out effective medications from the ineffective ones lost in the mists of time. Similarly in psychiatry, a winnowing process of mere tens and hundreds of years has distilled a good deal of the collective wisdom of the profession. It is, in other words, possible to think about historical diagnoses as having the potential of cutting nature closer to the joints than do current diagnostic systems, drawn up on the basis of whim, fad, and consensus.[1]

There are, in disease classifications, lumpers and splitters. The DSM has taken splitting over the side of the cliff. Philippe Pinel (1801) was the first lumper. The present effort at classification also is a lumping nosology that tries to discern diseases on the basis of biology and historical integrity. It is not meant to be absolutely inclusive of all psychiatric disorders but to convey some notion of how the main ones should be classified in a way that corresponds better than the present system to natural disease entities. In the absence of definitive biological verifications of many disorders, we have as our guide to “nature” the diagnostic traditions of a century and a half of scientific psychiatry, incubated in Germany and France, and brought today to great blossom in the transatlantic community.

Subsequent versions will need to come to grips with the addictions and the adult dementias. Personality disorders have not been included.

IV. Chronic psychosis: Kraepelin’s disease. (melancholic syndrome with or without mania; biological markers: DST, cortisol, sleep markers) This includes such entities as vascular depression. On a lifetime basis, one should rather think of “para-melancholia,” in which patients are at continuous risk of psychotic complications.

(b) atypical depression (Note that this is distinct from the depression of what used to be called “bipolar disorder” and corresponds to the depressive disease described by William Sargant and Donald Klein.)

(c) OCD

(d) phobias

(e) paroxystic anxiety (“panic attacks”) (biological marker: various

panicogens)

VIII. Delirium

IX. Breakdowns in the mind-body relationship

X. CHILD

As adult, except for:

—Intellectual disability/learning disabilities

—Autism/catatonia with or without psychosis

—Hyperactivity syndromes (biological marker: abnormal EEG)

—The childhood anxiety disorders, including separation anxiety

Notes

II. Neuropsychiatric presentations are not in DSM but should be. There is widespread agreement among clinicians that epilepsy, for example, has its own psychiatric pathology.[2] One senior American psychopathologist, Michael Alan Taylor, argues that psychiatry has erred seriously in omitting neuropsychiatric indications from the nosology[3], and this should be corrected. We make an early start here with epilepsy and Parkinsons..

III. This form of chronic psychosis splits the former “schizophrenia” into chronic psychotic disorders that partially remit, and those that do not.

(NB: positive symptoms may well be present, but they are not essential for the diagnosis of chronic psychosis.)

“Schizophrenia” has been given here an overdue burial and replaced with several different forms of chronic psychosis that demolish the former firewall between psychosis and affect. While abolishing the firewall, this nosology does restore the dividing line between “psychosis” and “neurosis,” although the latter term is shunned in favor of “nervous,” or the more modern-sounding but clunkier “non-melancholic, non-atypical depression. “

On the separation of hebephrenia from other forms of chronic psychosis: hebephrenia does not carry a disastrous prognosis, even though there is no restitutio ad integrum.[4] Hebephrenia is further distinguished by its onset in adolescence.[5] In DSM-3 the hebephrenic subtype became the “disorganized type”; it was filled with catatonic symptoms, and was relentlessly progressive, none of which is true of Hecker’s original “hebephrenia.” The DSM description also perpetuated the myth of the patients being “silly.” Even though the subtypes have vanished from DSM-5, a disaggregation of “schizophrenia” is long overdue, and this represents a first step.

The term “personality disintegration” is used in the sense of W. Mayer-Gross et al (1954) in preference to the term “dementia.”[6]

IV. On Kraepelin’s disease, meaning “melancholic syndrome with or without mania,” this nosology basically restores the unity of Kraepelin’s “manic depressive illness” that he first formulated in the 6th edition of his textbook in 1899, bringing together all the various depressions, of whatever polarity, together with the manias, whether they occurred in the same illness episode or not. This nosology follows the current of not considering mania and hypomania as separate illnesses[7]; nor are they part of “bipolar disorder,” as the DSM series presents it, because this version of affairs ignores bipolar disorder.

This nosology tackles head-on the issue of the “Kraepelinian dichotomy,” the firewall that Emil Kraepelin constructed between dementia praecox and manic-depressive illness in 1899.[8] A fundamental issue in the classification of melancholia is whether it belongs under the psychoses or the non-psychoses. The recent nosological tendency has been to consider psychotic melancholia (psychotic depression) as a rather anomalous subform of melancholic disease, which, in general, does not involve delusions or hallucinations.[9] In my view, this issue needs to be re-thought. The lower boundary of “psychosis” needs to be pushed downward, beneath formal and systematized delusions, to include fixed ideas and highly eccentric notions. It is true that most melancholic patients do not have systematized delusions or hallucinations. Still, in the words of Tom Bolwig, “They suffer from unjustified feelings of guilt, they don’t accept being ill, and they are unresponsive to all attempts at psychotherapy. Isn’t that a deficiency in their reality testing, and thus a forme fruste of psychosis?” [10]

On a lifetime basis, psychosis may well be more common in melancholia than has been thought to date (a common assessment is 30 percent – yet the authors Michael Alan Taylor and Max Fink stipulate that an additional number of patients with forme fruste fixed ideas and delusive suspicions should be added on.[11]). The percent of melancholics who on a lifetime basis may at some point or another be, or have been, psychotic is among the most difficult statistics to nail in the literature, because, as soon as a depressive patient becomes psychotic, the diagnosis is changed to “schizophrenia,” or “schizoaffective disorder.” It is true that DSM accepts the category “psychotic depression,” but it is quite underused. (There is also an ascertainment problem. As one observer pointed out in 1970: “It is well known that the more we like a patient, the less likely we are to place him on the psychotic end of the psychiatric spectrum.”[12] )

Many European authors considered melancholia basically a psychotic disorder. As Wilhelm Griesinger noted in the influential second edition of his textbook in 1861, “The core of [the psychic depressive conditions] consists of the pathological prevalence of a distressing, depressive, negative affect. . . . Corresponding to the mood there then appear false ideas and judgments that have no external basis, true delusions, distressing and painful in content.” [13] Such authoritative statements continue into the present-day literature as well: At a conference in 1991 Joseph Zubin reflected, “Many outstanding diagnosticians first decide whether the patient before them has a psychosis, and then, after that decision is made, go on to determine whether it is schizophrenia or manic-depressive. . . . Is it possible that what is the basic feature of the illness is psychosis, and that it takes the direction of either manic-depressive psychosis or schizophrenia depending on other factors . . . ?”[14]

In an effort to straddle this as yet unclarified issue of lifetime prevalence of psychosis in melancholic illness, the term “para” has been added to the lifetime version.

On the classification of melancholia, the disorder classically has been said to occur in two versions: (1) anxious, agitated (Angstmelancholie), and (2) stuporous (melancholic stupor). There is no evidence that these represent separate diseases but are, rather, separate presentations. There is a body of literature suggesting that psychotic anxiety exists as a separate diagnosis.[15][16]

In the spirit of Kraepelin, mania has been abolished as a separate disease and so there is no “bipolar disorder.” It makes little sense to classify depressions on the basis of polarity, as the depression of bipolar disorder seems to be melancholic in nature, and identical to the melancholic version of unipolar depression (“major depression”).[17] DSM-5 now accepts that bipolar and unipolar depression are identical, and calls both “major depression.”

“Major depression,” as well, has not found a place in this nosology on the grounds that it is highly heterogeneous, mixing together melancholic and non-melancholic illness.[18]

On the basis of etiology, there are many “depressions,” such as vascular depression, alcoholic depression, the depression of Parkinson’s, and so forth. Yet it is unclear that any of these depressions have a distinctive psychopathology not included under either melancholia or non-psychotic nervous disease. As science elaborates the existence of other distinctive depressions, these should be added to the nosology. Bernard Carroll has raised a thoughtful objection to letting psychopathology drive the nosology: “Aren’t you getting it backwards? Our nosology requires distinctive disorders with distinctive etiologies. The form of psychopathology is just one plank in the platform, not the main thing.”[19] One can only respond that this view is indeed correct. And if we were certain of the distinctive etiologies, we would, of course, let them drive the nosology. But since we are not quite there yet, driving the nosology with psychopathology is a pis aller.

VII. The classification of what used to be called “nervous disease” has bedeviled psychiatry for a century and a half, ranging through “nerves,” to “psychoneurosis,” to the current avalanche of micro-diagnoses. The present nosology tries to lessen reliance on the term “depression,” which has been badly stretched out of shape by overuse. It has also seemed judicious to revive the classic term “nervous disease,” as has ben recently suggested.[20] The present version of the nosology seeks a compromise with the use of both terms, depression and nerves.

VII (a) Mixed depression-anxiety has been called “cothymia” by Peter Tyrer.[21] It was the commonest form of depressive illness (with the exception of the psychoanalytic term “depressive neurosis”) in the decades before the appearance of DSM-3 in 1980, which sundered depression and anxiety.

VII (c-e) There is no special line in the nosology for adult anxiety, or any of the DSM “anxiety disorders,” several of which have now been shifted to the nervous category.

On removing OCD from the “anxiety disorders” as classified in DSM-4: the present nosology argues that OCD be made a “nervous” disease, which simply means a non-psychotic, non-melancholic disorder the proper classification of which will have to await further research. Patients with OCD do not display the classic somatic symptoms of anxiety, such as racing pulse, dizziness, sweating and tremor, nor the fear and dread of a panic attack. Rather, the obsessive patient is uneasy and apprehensive about his or her symptoms, while fully recognizing that they are unjustified and unrealistic.

On the omission of PTSD from the nosology: Traumatic neurosis was first described in the late 19th century, and belongs among the classic “nervous complaints.” Patients who have experienced severe trauma, in wartime or otherwise, may indeed become symptomatic, but that their symptoms (“the full diagnostic criteria” in DSM terms) first occur after some unspecified duration — which is the essence of “post” — is not at all clear. The whole diagnosis resulted from a systematic campaign of the Vietnam veterans in the late 1970s, and as a political construct PTSD has little place in a scientific classification of disease.

IX. Breakdowns in the mind-body relationship: There needs to be a category for what used to be called “hysteria,” “conversion disorder,” and so forth, symptoms that present in a medical way but are caused by the action of the mind.

Similarly, the personality disorders have been omitted from the nosology as they are considered a holdover from psychoanalysis and may well be abolished in ICD-11.

X. The classification of childhood disorders poses a special conundrum, because “pure” anxiety without depression is commoner in children than in adults. Children with “pure” depression more often present as angry. In the adult section these issues are classified under “mixed depression-anxiety.”

It is now considered possible that hyperactivity has a biological EEG test. [22] This revives Charles Bradley’s original 1938 view of the EEG in hyperactivity.[23]

[1] Shorter E. “The History of DSM,” in Making the DSM-5: Concepts and Controversies, ed. Joel Paris and James Phillips. New York: Springer, 201), 3–19, doi 10.1007/978-1-4614-6504-1_1

Every year, more and more Americans are treated for complaints of depression and often do not derive relief from treatment for their symptoms that may include anxiety, fatigue, poor sleep, and physical problems.

According to acclaimed historian of psychiatry, Dr. Edward Shorter, the diagnosis of depression has increased steadily over the past forty years and, during our lifetimes, “one American in five will receive a diagnosis of depression.” That’s more than sixty million people.

Edward Shorter, Hannah Professor in the History of Medicine and Professor of Psychiatry at the University of Toronto (and recent contributor to our new How I Became a Historian of Psychiatry series), wrote a piece for the Scientific American blog which was published on Wednesday.

The article, entitled “Trouble at the Heart of Psychiatry’s Revised Rule Book“, deals with the DSM and starts thus:

One might liken the latest draft of psychiatry’s new diagnostic manual, the DSM-5, to a bowl of spaghetti. Hanging over the side are the marginal diagnoses of psychiatry, such as attention deficit hyperactivity disorder and autism, important for certain subpopulations but not central to the discipline.

At the center of the spaghetti bowl are the diagnoses at the heart of psychiatry: major depression, schizophrenia, bipolar disorder.

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For the second installment of the “How I became a historian of psychiatry” series, Edward Shorter, Hannah Professor in the History of Medicine and Professor of Psychiatry at the University of Toronto, author among others of A History of Psychiatry from the Era of the Asylum to the Age of Prozac (1997) and From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era (1992), kindly shares his intellectual biography with the H-Madness community:

This story began in 1967 when, a fresh young history PhD graduate, I came to the University of Toronto. I had been trained as a social historian and after several projects far away from the history of medicine, in 1975 I wrote a general history of the family, not that it was such a medical contribution – but it called my attention to a number of medical issues in the lives of women historically: infected abortion, weariness from overwork, and iron-deficiency anemia. This led to a history of women’s health care (Women’s Bodies) in 1982. This was full-blast medical history, but researching it made me aware that I knew almost nothing of medicine. So I went to medical school for two years, taking all the basic medical sciences.

I now felt better equipped to take on a big problem: the history of psychosomatic illness, especially “hysteria,” mainly in women, over the centuries. Knowing something about medicine was helpful here because of the difficulty in sorting out symptoms that are psychogenic (“hysteria”) from those that are organic-medical, such as endometriosis, often dubbed “hysterical” in the past. This research resulted in From Paralysis to Fatigue (1992).

I was now thoroughly enmeshed in psychiatry, and went on to write a general history of the discipline, which appeared in 1997 and was read by a number of psychiatrists. I became friendly with several whose work I greatly admired, and who subsequently influenced the direction of my own studies, in particular David Healy, Max Fink, Bernard Carroll, Tom Ban, Tom Bolwig, and Gordon Parker. Animated email exchanges with this group produced a sharp research interest on my part in two themes: the history of diagnosis (nosology), and the history of psychiatric medications (psychopharmacology). This led to a string of publications: A History of Shock Therapy, with David Healy (2007), Before Prozac (2009), and Endocrine Psychiatry; Solving the Riddle of Melancholia (with Max Fink) in 2010. My latest book, The Rise and Fall of the Nervous Breakdown – And How Everyone Became Depressed, will be published by Oxford early in 2013. I should say that among contemporary historians of psychiatry there are also several whose work I have learned from, in particular Patrizia Guarnieri and Ian Dowbiggin. Everyone in our field learned from Roy Porter.

There are two points of more general interest in this cascade of self-esteem: (1) Historians of psychiatry have a real contribution to make to clinical psychiatric diagnosis, subject as it is to the buffeting of fashion and fad; that contribution lies in surveying the enormous historical experience of psychiatry to see which diagnoses seem to correspond most closely to natural disease entities. (2) Psychiatric historians also have a contribution to make to therapeutics, because many past therapies have been discarded not because they were unsafe or ineffective, but because the patents expired! Or because (as in the case of electroconvulsive therapy) society turned against them for non-scientific reasons. Or because, as in the case of the barbiturates, makers of newer drug classes scorned them in advertising as old-fashioned and risky.

Among my current interests are pediatric catatonia and self-injury behavior in autism, and the extent to which they have been relieved in the past with ECT; the early “tranquilizers” and sedatives, discarded as effective treatments largely because of psychiatric urban myths of various kinds; and melancholia as a distinctive illness in its own right with characteristic biological markers. I find this research tremendously exciting, and hope that historian colleagues will become involved.